Provider Demographics
NPI:1477175545
Name:ACTIVE LIFE HEALTH OF GARDEN CITY MEDICAL PLLC
Entity Type:Organization
Organization Name:ACTIVE LIFE HEALTH OF GARDEN CITY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-928-1697
Mailing Address - Street 1:623 STEWART AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4771
Mailing Address - Country:US
Mailing Address - Phone:516-331-2082
Mailing Address - Fax:516-784-5232
Practice Address - Street 1:311 NORTH ST STE 406
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-2217
Practice Address - Country:US
Practice Address - Phone:914-785-7752
Practice Address - Fax:914-363-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies